Provider Demographics
NPI:1770772865
Name:ROTH, LEIGH DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:DIANE
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:DIANE
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2165 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-8809
Mailing Address - Country:US
Mailing Address - Phone:828-324-2800
Mailing Address - Fax:828-294-9141
Practice Address - Street 1:2165 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-8809
Practice Address - Country:US
Practice Address - Phone:828-324-2800
Practice Address - Fax:828-294-9141
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06090363A00000X
IL085.003735363AM0700X
MN10374363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical